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THE CAPITATION FEE
1353
THE LANCET LONDON:SATURDAY, JUNE S, 1937
THE CAPITATION FEE THE national health insurance system, in the twenty-fifth year of its age, is again faced with the problem of making an equitable adjustment in the capitation fee paid to the practitioners responsible for the medical care of the 18 million insured persons in Great Britain, a number which it is proposed to increase by the addition of approximately 1 million juveniles entering insurable employment between leaving school and reaching the age of 16. As on previous occasions, the Insurance Acts Committee of the British Medical Association, representing the practitioners, and the Government have been unable to reach agreement, and the question has, with the consent of both parties, been referred for determination to an independent court of inquiry. The present inquiry is simplified in that it is not to consider the question ab initio. It starts with the assumption that the capitation fee of 9s., awarded by a similar court in 1924, is to be taken as the proper remuneration at that time ; and the task of the present court is to ascertain what changes, if any, should be made in the capitation fee to meet the changes that have taken place since 1924 in the conditions under which insurance medical practice is carried on. The court of inquiry began its deliberations on May 26th, and the Ministry of Health and the Insurance Acts Committee have exchanged memoranda of evidence and rejoinders, all of which are reproduced in the supplement to the British Medical Journal of May 29th. The Committee contends that th6’ changes affecting insurance practice since 1924 justify an increase in the capitation fee from 9s. to 12s. 6d., and bases the contention on three main grounds. First, it is pointed out that recently, and especially within the last ten years, there has been a " reorientation of medical thought and a widening of the basis of medical practice," which now seeks not only to remove diseased conditions but to promote positive health. The increased responsibility and skill involved in such preventive work is not fully expressed in the increase in the number of the items of services rendered, but it is of definite value to the community and should be taken into account in assessing the remuneration of insurance practitioners. Moreover, the advance of medical science has increased the complexity of diagnosis and treatment and therefore the amount of time necessarily spent with individual patients. Secondly, the Committee produces evidence of an increase in the average annual number of attendances made to each person on a doctor’s list. In 1924 the number was estimated by the Minister
at 3-5, and by the Committee at 3-75. Since 1924 the Committee has arranged for the keeping of special records by practitioners in nearly all insurance committee areas, and has thus obtained particulars of over 3000 practices, which, it is contended, show that the average annual number of attendances per person on a doctor’s list in the years 1930-36 was 5-02. Thirdly, it is put forward that the ratio of practice expenses to gross receipts, which was taken by the 1924 court to be 25 per cent., is now 33 per cent. The Committee accepts the view of the Ministry that the fall in the cost of living would, other things being equal, justify a reduction of 5d. in the capitation fee, and that there has been some decrease in motoring costs -not more, however, than 4-6 per cent., corresponding to a reduction in the capitation fee of .—but it is contended that these reductions are far outweighed by the increased costs under other heads and by the increased responsibilities and efforts now required in insurance practice. The Committee emphatically rejects the Ministry’s view that the young workers proposed to be brought within the health insurance system will need less medical care than the general body of insured persons. The most important point at issue between the Ministry and the Committee is the extent of the increase in the work devolving upon insurance practitioners, and especially in the average number of services rendered to each person on a doctor’s list. According to the records specially kept at the instance of the Committee the number in 1930-36 was, as already stated, 5-02, but an examination made by the regional medical officers of the insurance medical records kept in 600 practices during 1936 showed that the number in those practices was 3.66 ; and it was found that while the number of surgery attendances had increased by 10-7 per cent. as compared with the results of a similar examination made in 1924, the number of visits had fallen by 3.8 per cent. To estimate the net effect of these changes, the visits and attendances were weighted in the ratio of 11 to 1 respectively, the average fee in private practice for a visit being usually about half as much again as the fee for a surgery attendance. The figures were corrected for the omission of records of persons dying during the period under review in each of the years in question; and when the weighting is applied to the figures so corrected the totals become 3-99 in 1924 and 4.12 in 1936, showing a net increase in services rendered of about 3tper cent.-which would be met by an increase of rather less than 4d. in the capitation fee, as against the 3s. 3d. claimed under this head by the Committee. In considering the contention that scientific advances have made insurance practice more exacting, the Ministry expresses the view that the improved methods have mainly affected specialist practice, and that such methods as have been adopted in general practice, for example the injection of varicose veins, have tended to reduce the total services required. The Ministry gives statistics drawn from insurance medical records and hospital reports which, it is suggested, afford
1354 evidence that " insurance
practitioners
have been
relieved of some of the more onerous part of their work by recent developments of health services." As regards motoring costs, the estimate in the Committee’s memorandum assumes the use of a 15-h.p. model, which it is stated, " is perhaps typical of the car most commonly employed in general practice," and a running cost based on petrol consumption at the rate of 20 miles per gallon. The Ministry’s figures are based on a car of 9 to 10 h.p. consuming petrol at the rate of 32 miles per gallon. There is an acute difference of opinion on the question of the work that would devolve upon practitioners by bringing persons under 16 years into insurance on their entering insurable employment. The Committee presses the view that though in providing medical care for these young people a practitioner’s duties will be to a considerable extent preventive and advisory-that he will be concerned less with incapacity than with positive instruction in health and in the early detection and treatment of disease-they will be none the less onerous. For such persons the services though different in kind practitioner’s will be more rather than less important than those rendered to other members of the insured population. It is urged that the period of " transition from the sheltered years of school life to the early years of wage-earning is very commonly a difficult and trying one, when the friendly supervision of the family doctor is of paramount importance," and that therefore the new responsibilities it is proposed to entrust to insurance practitioners will be specially important, not only from the point of view of the individual patients but from that of the community of which they form part. The Ministry agrees that the period of young adolescence is important for future health, but holds that it does not follow that persons of the age in question require more treatment than older persons, or "that in practice they will demand or receive more treatment " ; and from evidence drawn chiefly but perhaps not very appropriately from mortality-rates, incapacitating sickness experience, and insurance medical records, it is submitted that the claims which this new class of insured persons are likely to make on the time and energy of insurance practitioners may reasonably be assessed at about half those made by an equivalent number of older insured persons. The Ministry concludes, however, that there should be one uniform capitation fee for all insured persons, including thejuveniles, and that the fee should be 8s. The chief impression left by the study of the four able documents now published is that the court of inquiry has still a good deal of ground to explore. The discrepancies between the estimates made by the Ministry and the Committee respectively of the services to be rendered by insurance practitioners, and of the costs that will be entailed in rendering the services, are so great that further information seems needed of the data on which the estimates were based, and the methods employed in handling these data. In the arguments put forward there appears to be some difference of
outlook and emphasis. The Ministry seems to consider the question of remuneratiori in terms of separate items of service-from a strictly quantitative point of view. The Committee, on the other hand, rightly emphasises the importance of considering also the kind and degree of the responsibility assumed. This is in harmony with the general principle on which the capitation system of payment is based ; for in that system the doctor is paid, not-as in the attendance system-for work done but in proportion to the responsibilities he shoulders. The court was instructed to have regard in its inquiry to " other relevant factors " and not the least of these is the attainment of the willing cooperation of insurance practitioners in the greatest of national services.
NOVEL METHOD OF ADMINISTERING HORMONES issue of April llth last year experiments recorded showing that the effectiveness of testosterone could be much increased by augmenting the volume of oily medium used for injection or by adding fatty acid to the solution. The effect was probably due to retardation of absorption and decrease of wastage of the hormones. In an annotation we then drew attention to the parallelism between these experiments and earlier work on increasing the effectiveness of cestrone and oestradiol by subdivision of the total dose or by esterification. Soon afterwards the preparation and biological examination of a long series of aliphatic esters of testosterone led to the selection of the propionate as giving the optimum combination of intensity and duration of action,l and it was shown that, on castrate rats, a constant total dose of testosterone was more efficient given IN
our
were
as propionate once weekly than given as free hormone twice dailv.2 More recently further tests have been carried out with the esters of oestrone and cestradiol, both on rats 3 and on the feather response of brown Leghorn capons.44 By the latter test it can be shown that whereas 1 mg. of free cestradiol in one dose has an effect lasting barely one day, 1 mg. as 3-benzoate has an effect lasting ten days, and 1 mg. as 3-benzoate-17-acetate one lasting fifteen days. It seemed likely that this effect of esterification depended on either alteration of the solubility of the compound, resulting in slower absorption from the site of injection, or prolonged liberation of free hormone from slow hydrolysis of the esters. Some interesting experiments now reported by DEANESLY and PARKES 5 have a bearing on these It was found that with androalternatives. stanediol and trans-androstanediol an increase in the volume of oily medium actually decreased the effectiveness. These compounds are relatively and the more concentrated solutions insoluble,
1 Ruzicka, L., and Wettstein, A. (1936) Helv. chim. Acta, 19, 1141 ; Miescher, K., Wettstein, and Tschopp, E. (1930) Biochem. J. 30, 1977. 2 Parkes, A. S. (1936) Lancet, 2, 674. 3 Miescher, Schulz, C., and Tschopp (1937) Schweiz. med. Wschr. 67, 268. 4 Parkes (1937) Biochem. J. 21, 579. 5 Deanesly, R., and Parkes (1937) Chem. and Ind. 56, 447.
THE LANCET LONDON:SATURDAY, JUNE S, 1937
THE CAPITATION FEE THE national health insurance system, in the twenty-fifth year of its age, is again faced with the problem of making an equitable adjustment in the capitation fee paid to the practitioners responsible for the medical care of the 18 million insured persons in Great Britain, a number which it is proposed to increase by the addition of approximately 1 million juveniles entering insurable employment between leaving school and reaching the age of 16. As on previous occasions, the Insurance Acts Committee of the British Medical Association, representing the practitioners, and the Government have been unable to reach agreement, and the question has, with the consent of both parties, been referred for determination to an independent court of inquiry. The present inquiry is simplified in that it is not to consider the question ab initio. It starts with the assumption that the capitation fee of 9s., awarded by a similar court in 1924, is to be taken as the proper remuneration at that time ; and the task of the present court is to ascertain what changes, if any, should be made in the capitation fee to meet the changes that have taken place since 1924 in the conditions under which insurance medical practice is carried on. The court of inquiry began its deliberations on May 26th, and the Ministry of Health and the Insurance Acts Committee have exchanged memoranda of evidence and rejoinders, all of which are reproduced in the supplement to the British Medical Journal of May 29th. The Committee contends that th6’ changes affecting insurance practice since 1924 justify an increase in the capitation fee from 9s. to 12s. 6d., and bases the contention on three main grounds. First, it is pointed out that recently, and especially within the last ten years, there has been a " reorientation of medical thought and a widening of the basis of medical practice," which now seeks not only to remove diseased conditions but to promote positive health. The increased responsibility and skill involved in such preventive work is not fully expressed in the increase in the number of the items of services rendered, but it is of definite value to the community and should be taken into account in assessing the remuneration of insurance practitioners. Moreover, the advance of medical science has increased the complexity of diagnosis and treatment and therefore the amount of time necessarily spent with individual patients. Secondly, the Committee produces evidence of an increase in the average annual number of attendances made to each person on a doctor’s list. In 1924 the number was estimated by the Minister
at 3-5, and by the Committee at 3-75. Since 1924 the Committee has arranged for the keeping of special records by practitioners in nearly all insurance committee areas, and has thus obtained particulars of over 3000 practices, which, it is contended, show that the average annual number of attendances per person on a doctor’s list in the years 1930-36 was 5-02. Thirdly, it is put forward that the ratio of practice expenses to gross receipts, which was taken by the 1924 court to be 25 per cent., is now 33 per cent. The Committee accepts the view of the Ministry that the fall in the cost of living would, other things being equal, justify a reduction of 5d. in the capitation fee, and that there has been some decrease in motoring costs -not more, however, than 4-6 per cent., corresponding to a reduction in the capitation fee of .—but it is contended that these reductions are far outweighed by the increased costs under other heads and by the increased responsibilities and efforts now required in insurance practice. The Committee emphatically rejects the Ministry’s view that the young workers proposed to be brought within the health insurance system will need less medical care than the general body of insured persons. The most important point at issue between the Ministry and the Committee is the extent of the increase in the work devolving upon insurance practitioners, and especially in the average number of services rendered to each person on a doctor’s list. According to the records specially kept at the instance of the Committee the number in 1930-36 was, as already stated, 5-02, but an examination made by the regional medical officers of the insurance medical records kept in 600 practices during 1936 showed that the number in those practices was 3.66 ; and it was found that while the number of surgery attendances had increased by 10-7 per cent. as compared with the results of a similar examination made in 1924, the number of visits had fallen by 3.8 per cent. To estimate the net effect of these changes, the visits and attendances were weighted in the ratio of 11 to 1 respectively, the average fee in private practice for a visit being usually about half as much again as the fee for a surgery attendance. The figures were corrected for the omission of records of persons dying during the period under review in each of the years in question; and when the weighting is applied to the figures so corrected the totals become 3-99 in 1924 and 4.12 in 1936, showing a net increase in services rendered of about 3tper cent.-which would be met by an increase of rather less than 4d. in the capitation fee, as against the 3s. 3d. claimed under this head by the Committee. In considering the contention that scientific advances have made insurance practice more exacting, the Ministry expresses the view that the improved methods have mainly affected specialist practice, and that such methods as have been adopted in general practice, for example the injection of varicose veins, have tended to reduce the total services required. The Ministry gives statistics drawn from insurance medical records and hospital reports which, it is suggested, afford
1354 evidence that " insurance
practitioners
have been
relieved of some of the more onerous part of their work by recent developments of health services." As regards motoring costs, the estimate in the Committee’s memorandum assumes the use of a 15-h.p. model, which it is stated, " is perhaps typical of the car most commonly employed in general practice," and a running cost based on petrol consumption at the rate of 20 miles per gallon. The Ministry’s figures are based on a car of 9 to 10 h.p. consuming petrol at the rate of 32 miles per gallon. There is an acute difference of opinion on the question of the work that would devolve upon practitioners by bringing persons under 16 years into insurance on their entering insurable employment. The Committee presses the view that though in providing medical care for these young people a practitioner’s duties will be to a considerable extent preventive and advisory-that he will be concerned less with incapacity than with positive instruction in health and in the early detection and treatment of disease-they will be none the less onerous. For such persons the services though different in kind practitioner’s will be more rather than less important than those rendered to other members of the insured population. It is urged that the period of " transition from the sheltered years of school life to the early years of wage-earning is very commonly a difficult and trying one, when the friendly supervision of the family doctor is of paramount importance," and that therefore the new responsibilities it is proposed to entrust to insurance practitioners will be specially important, not only from the point of view of the individual patients but from that of the community of which they form part. The Ministry agrees that the period of young adolescence is important for future health, but holds that it does not follow that persons of the age in question require more treatment than older persons, or "that in practice they will demand or receive more treatment " ; and from evidence drawn chiefly but perhaps not very appropriately from mortality-rates, incapacitating sickness experience, and insurance medical records, it is submitted that the claims which this new class of insured persons are likely to make on the time and energy of insurance practitioners may reasonably be assessed at about half those made by an equivalent number of older insured persons. The Ministry concludes, however, that there should be one uniform capitation fee for all insured persons, including thejuveniles, and that the fee should be 8s. The chief impression left by the study of the four able documents now published is that the court of inquiry has still a good deal of ground to explore. The discrepancies between the estimates made by the Ministry and the Committee respectively of the services to be rendered by insurance practitioners, and of the costs that will be entailed in rendering the services, are so great that further information seems needed of the data on which the estimates were based, and the methods employed in handling these data. In the arguments put forward there appears to be some difference of
outlook and emphasis. The Ministry seems to consider the question of remuneratiori in terms of separate items of service-from a strictly quantitative point of view. The Committee, on the other hand, rightly emphasises the importance of considering also the kind and degree of the responsibility assumed. This is in harmony with the general principle on which the capitation system of payment is based ; for in that system the doctor is paid, not-as in the attendance system-for work done but in proportion to the responsibilities he shoulders. The court was instructed to have regard in its inquiry to " other relevant factors " and not the least of these is the attainment of the willing cooperation of insurance practitioners in the greatest of national services.
NOVEL METHOD OF ADMINISTERING HORMONES issue of April llth last year experiments recorded showing that the effectiveness of testosterone could be much increased by augmenting the volume of oily medium used for injection or by adding fatty acid to the solution. The effect was probably due to retardation of absorption and decrease of wastage of the hormones. In an annotation we then drew attention to the parallelism between these experiments and earlier work on increasing the effectiveness of cestrone and oestradiol by subdivision of the total dose or by esterification. Soon afterwards the preparation and biological examination of a long series of aliphatic esters of testosterone led to the selection of the propionate as giving the optimum combination of intensity and duration of action,l and it was shown that, on castrate rats, a constant total dose of testosterone was more efficient given IN
our
were
as propionate once weekly than given as free hormone twice dailv.2 More recently further tests have been carried out with the esters of oestrone and cestradiol, both on rats 3 and on the feather response of brown Leghorn capons.44 By the latter test it can be shown that whereas 1 mg. of free cestradiol in one dose has an effect lasting barely one day, 1 mg. as 3-benzoate has an effect lasting ten days, and 1 mg. as 3-benzoate-17-acetate one lasting fifteen days. It seemed likely that this effect of esterification depended on either alteration of the solubility of the compound, resulting in slower absorption from the site of injection, or prolonged liberation of free hormone from slow hydrolysis of the esters. Some interesting experiments now reported by DEANESLY and PARKES 5 have a bearing on these It was found that with androalternatives. stanediol and trans-androstanediol an increase in the volume of oily medium actually decreased the effectiveness. These compounds are relatively and the more concentrated solutions insoluble,
1 Ruzicka, L., and Wettstein, A. (1936) Helv. chim. Acta, 19, 1141 ; Miescher, K., Wettstein, and Tschopp, E. (1930) Biochem. J. 30, 1977. 2 Parkes, A. S. (1936) Lancet, 2, 674. 3 Miescher, Schulz, C., and Tschopp (1937) Schweiz. med. Wschr. 67, 268. 4 Parkes (1937) Biochem. J. 21, 579. 5 Deanesly, R., and Parkes (1937) Chem. and Ind. 56, 447.